Police related deaths

Concerns summary A S.136 Mental Health Act assessment was conducted without critical information or discussion with relevant police, indicating an urgent need to review S.136 procedures.

Concerns summary Healthcare professionals used inconsistent and subjective criteria for assessing suicide risk, not following training materials, leading to inaccurate risk grading and no plan to rectify this critical issue.

Concerns summary Systemic and individual failures in police information sharing meant critical concerns from a psychiatrist about a vulnerable missing person's psychotic relapse were not recorded or relayed to other officers or agencies.

Concerns summary The police Missing Person Policy requires review to ensure it is fit for purpose and adequately addresses risks.

Concerns summary Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.

Concerns summary Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation and storage, despite their lethal capabilities, poses a significant public safety risk.

Concerns summary A lack of joint police-health policies for vulnerable missing persons, absence of multi-agency meetings, inadequate police mental health training, and poor information sharing protocols hindered effective risk assessment and search efforts.

Concerns summary The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.

Concerns summary Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.

Concerns summary Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.

Concerns summary Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.

Concerns summary Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.

Concerns summary Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.

Concerns summary Inconsistent police training and guidance regarding PAVA spray use and forcible mouth searches for detained persons with objects in their mouths, conflicting with FFLM recommendations, indicates a systemic failure to implement past lessons.

Concerns summary Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.

Concerns summary There is a critical lack of protocol and training for monitoring non-detained individuals in police stations, including guidance on interpreting snoring, the impact of intoxication, and effective information sharing.

Concerns summary Police officers lacked formal training for handling complex situations like Miss Devanney's, raising concerns about appropriate responses in similar future circumstances.

Concerns summary Police officers require full and adequate training to thoroughly interrogate all details relating to warning markers held on the PNC to prevent future deaths.

Concerns summary Police failed to act on reported threats and share critical information with mental health services, leading to a flawed psychiatric assessment and early discharge of a high-risk individual with significant mental health issues.

Concerns summary Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.